Targets and poor organisational environments to blame for patient neglect

Management targets that direct nurses and doctors to treat care and compassion as a low priority, poor working relationships and culture which results in healthcare staff being unable (or unwilling) to prevent poor care, and overwhelming workloads which can cause staff burnout and compassion fatigue are key cause for ‘patient neglect’ academics at LSE have found.

‘Patient Neglect in Healthcare Institutions’, published in the BMC: Health Service Research journal, is the first systematic literature review on the nature, frequency and causes of patient neglect in hospitals. Dr Tom Reader and Dr Alex Gillespie evaluated all articles and reports published in English since 1990 reporting empirical data on patient neglect occurring anywhere in the world. The review found very few studies to have investigated patient neglect, with research in healthcare organisations preferring to focus upon the concept of 'medical error'. This is in contrast to growing public concern over the issue of patient neglect, especially after Mid-Staffordshire Trust scandal.

In order to differentiate patient neglect from medical error or the breaking of organisational care standards (termed 'procedure neglect'), the authors outline the notion of 'caring neglect'. This refers to instances of poor care by healthcare staff that are indicative of a poor attitude, for example a lack of compassion towards patients, yet cannot be considered 'mistakes'. Critically, caring neglect is challenging for healthcare organisations to prevent, as the behaviours associated with caring neglect (e.g. compassion, listening, attitude, and ignoring patients) are difficult to proceduralise or monitor.

They authors found that caring neglect is likely to be the result of a combination of personnel factors and poor organisational management. In particular, where management focus on task-led targets which reward staff for completing specific goals or activities, caring behaviours that cannot be easily measured are seen as unproductive.

High workload were also found to cause patient neglect, frequently creating situations where staff did not have the time to engage in ‘caring’ behaviours such as listening to patients or responding quickly to their requests. High workloads were also found result in staff burnout. This is associated with neglect because healthcare staff experiencing burnout "start to display negative attitudes, emotions and behaviours due to burnout which can result in detached and cynical attitudes and a lack of empathy or compassion.”

“Our research revealed that neglect occurs due to a combination of organisational structures that prevent healthcare staff to ‘care’ for patients, such as high workloads and a poor working environment, as well as organisational metrics and targets of care that do not consider the softer aspects of healthcare, for example compassion” said Dr Tom Reader. “This then directs the behaviour of healthcare staff, often away from care and towards bureaucracy, and shapes how they feel and think about patients (e.g. burnout). It means that simply altering regulation and ‘making’ healthcare staff (e.g. through training) show compassion and empathy for patients will have little effect for improving the quality of healthcare.”

“We found that management prioritisation of task-focused targets over ‘caring’ activities such as taking time to answer patient’s questions or ensuring they are comfortable also contributes to poor patient care” said Dr Alex Gillespie. “Healthcare providers should be aware that staff can be pushed towards having ‘tunnel vision’ if they are either too pressured for time or are rewarded for completing specific tasks over others”. This can potentially de-prioritise unmeasured activities related to procedure and caring neglect.

“In cases such as mid-Staffordshire, for example, job insecurity, lack of resources, poorly managed change and incoherent management all served to create conditions for neglect to occur. High workloads, stress and poor leadership resulted in staff being constrained in their ability to provide good care, alongside creating widespread de-motivation, burnout and disengagement in providing patient care.” Accordingly, the authors argue, blame should be shifted from staff to management targets and poor organisational environments.

Dr Tom Reader, is a lecturer in Organisational and Social Psychology and a Chartered Applied Psychologist.

Dr Alex Gillespie is a lecturer in Social Psychology and Co-Editor of the Journal for the Theory of Social Behaviour.

Both are based at the Department of Social Psychology, London School of Economics and Political Science.

Caring neglect refers to failings in care that are below the threshold of being proceduralised (and are unlikely to cause immediate harm), yet lead patients, family and the public to believe that staff are unconcerned about the emotional and physical wellbeing of patients. This pertains to patient perspectives (or those of families and other caregivers), and specifically attributions about staff being uncaring. Caring neglect might include not being helped to eat, not being treated with dignity and respect, or having concerns dismissed. None of these behaviours are likely to violate a regulation or protocol, nevertheless, they could be taken as indicating caring neglect by patients.

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